Christina Applegate's Breast Cancer: FAQ

Aug. 4, 2008 -- Actress Christina Applegate, 36, is being treated for early-stage breast cancer and is expected to recover fully. Her publicist announced the diagnosis on Saturday, according to media reports.

Applegate's breast cancer, which was found early through a doctor-ordered MRI, isn't life-threatening, her publicist said.

No other details about Applegate's breast cancer, including its specific stage and treatment, have been made public. Applegate, star of the ABC comedy Samantha Who?, has a family history of cancer -- her mother has had breast cancer and cervical cancer.

How common is breast cancer in young women. If Applegate got an MRI, should other women do the same? And what might her treatment involve?

Friedman says breast cancer is "relatively uncommon" in young women. The American Cancer Society's records for 2000-2004 show that 95% of new cases and 97% of breast cancer deaths happened in women age 40 and older and the median age at diagnosis was 61.

What might Applegate's treatment involve?

I don't know what [early stage] means. Early stage can mean different things to different people. Is it noninvasive, invasive? It's hard to talk about things when you don't know specifics, so let's talk about both.

Intraductal cancer, also known as DCIS [ductal carcinoma in situ], is stage 0 breast cancer. It's a noninvasive breast cancer. Many times, you'll do a lumpectomy. If it's really extensive, you might do a mastectomy, but they don't need chemotherapy. And if you have a lumpectomy, more than likely you'll get radiation; sometimes you wouldn't.

If it's truly an invasive cancer, usually the most common is infiltrating ductal cancer. I would call an early stage something that we call stage 1, which means that the tumor is less than 2 centimeters and the lymph nodes are negative [contain no cancer].

The problem with that terminology is that there are still patients with early-stage breast cancer, depending on exactly how you use the terms, where you would end up giving chemotherapy to [them]. And most of us would not consider somebody who needs chemotherapy an early-stage breast cancer. And that's the problem with using those sorts of semantics.

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Once she's done with her treatment, what sort of long-term follow-up does someone need to get if they're young and they've already had breast cancer, whether it's stage 0 or stage 1?

From a breast cancer perspective, the follow-up is a little bit different depending on whether they have mastectomies or don't have mastectomies. If you've had bilateral mastectomies, then obviously you don't need mammograms. If you've had a mastectomy in one breast but you still have the other one, you need a mammogram, and if you had breast conservation, where you have both breasts, then you obviously need mammograms for both.

There's a couple of other issues that come up. No. 1, do you need to consider genetic testing? Because if you're having breast cancer in the 30s, again, it's relatively uncommon and you start thinking about do they have a family history, could they possibly have the breast cancer gene? So that would also impact how you would follow them.

The other issue is do you get breast MRIs, and that's extremely controversial.

Routine follow-up for women with breast cancer, even young women -- we'll presume they do not have the gene -- is physical exams every six months and routine mammography, and that's all.

Yes. You might do it a little bit more frequently for the first time or so but then after a year or so, no, then just back to once a year. There's no value in doing more frequent mammography than that.

Are breast cancers more aggressive in young women?

As a group, if you took 100 young women vs. 100 65-year-olds, yes. But what I always tell patients is it doesn't really matter what the whole group is; it matters what your particular tumor is. You will have more aggressive tumors in young women and fewer in older women. But the individual characteristics are really what's important to that patient.

Applegate's mother had breast cancer and cervical cancer. How does family history affect her risk?

Clearly because of the fact that her mom had breast cancer, you now have two people in the family with breast cancer. There's no family history of ovarian [cancer]?

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The report I saw said breast and cervical cancer but not ovarian cancer.

Cervical [cancer is] not related. But her risk of having the breast cancer gene is now up to 6%, 7% and there are different ways to calculate that. And now she's only 36 years old, her mom had breast cancer -- I'll presume it was postmenopausal -- so I'm at least having a conversation with her about genetic testing [if I were her doctor].

Applegate's breast cancer was found through MRI. It's not clear from her publicist's statement if this was her first, baseline MRI or if she's gotten other MRIs to screen for breast cancer. In March 2007, an expert panel convened by the American Cancer Society recommended that only women at high risk of breast cancer get annual MRI screening in addition to mammography. Where do you stand on MRI screening?

It depends what month you ask me. It is a very, very controversial topic. We are using the recommendations that you just alluded to. But there is no data -- the women who are getting routine MRI -- and I use that term in italics because I'm not sure exactly what that means, is that every year or every other year? -- are people who have the BRCA1 or BRCA2 [breast cancer] gene, which is why I think for somebody like her, it would be very important to do. Other than that, women who are at very high risk -- and very high risk in our practice means a Gail risk of 20% or higher.

Editor's note:The Gail risk model, which is for women who are at least 35 years old, estimates a woman's odds of developing breast cancer based on her current age, her age when she first menstruated, her age when she first gave birth, family history of breast cancer, past biopsies, and race.

We also look to see if they have dense breasts, because it makes it theoretically more difficult to read the mammogram. So in her particular case, even if she didn't test positive, she's clearly young, there's clearly a family history, she's clearly had a breast cancer, she probably has dense breasts given her age, I would certainly consider getting MRIs on her every year or every other year, probably every year. If she didn't have a family history and she's 55 and her breasts are a little bit less dense because she's had a couple of kids ... then I might not get that routine MRI.

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So I look at the other factors, look at what the mammogram looks like, have a conversation with the patient, but there is not a routine patient that I get routine MRIs on other than very high risk or BRCA1 or BRCA2 positive.

And the downside is the risk of false-positive results (suspicious findings that turn out not to be cancer)?

Oh yeah, and we can't afford it. I know people don't like to hear that answer, and for individual patient it's really not anything that plays a role in most of our decision making. But from a society perspective, if we started doing MRIs willy-nilly, I think there was an estimate last year ... probably in The Wall Street Journal, that we would spend something like a billion dollars a year between additional screening and biopsies for the things that come up. That's a lot of money, and we need to start making decisions that have some rational decisions from a medical-economic perspective. Again, not that you would apply that for an individual patient, because you never do that. But in making recommendations that are going to have societal implications, I think you have to do that.

Do you have patients asking you why can't I get an MRI? What do you tell someone who's not at high risk?

I try and give them the right answer ... and go through the false-positives. ... I don't know if you've had a mammogram ... it's not the most pleasant thing in the world but it's not horrible. You go in, you put your breasts on the thing, it squishes them, and you leave. I'm not trying to minimize it. But now you talk to the people who've had MRIs and they hate them. No. 1, you have to get an IV because it's given with contrast. No. 2, you're not getting squished but you're lying face down in this machine that drives people crazy, makes a lot of noise, you're in a very confined environment. People don't like it, and theoretically you can get renal insufficiency, kidney damage, from the dye. And so now we've gone from a test, a mammogram, where it's sort of uncomfortable but it's not going to do harm to you, to a test that's very expensive, has lots of false-positives, and can actually do harm. So you don't just do it because you think it's a good idea. That's the first thing I do -- I explain downsides to them. And if they still want it, I'll write them a prescription, but more than likely the insurance company is going to kick them out because it's so much more expensive.

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When you say kick them out, you mean refuse to do it.

Correct. They won't pay for it; they'll refuse to pay for it. Because they are clearly looking at breast MRI to make sure it meets justification.

What about ultrasound? Don't a lot of women get mammogram and ultrasound as well because of density?

You can, but ultrasound works really well if you know I need to look right around here because there was something on the mammogram or something the patient feels. When you have to screen the entire breast, it becomes a much more difficult test to do. ... [It] only looks at one small area of the breast at a time and you've got to move it all around the whole breast. It is very easy to miss things.

Do you think MRI is going to get refined to the point where there aren't as many false-positives?

It probably will. I'm not an MRI guru. I clearly think there are people working on that. I think the Germans have done a very good job with breast MRI. Look at mammography 30 or 40 years ago. They didn't do so great with it; we're clearly much better than we used to [be]. So do I think MRI will get refined? I do. Is it ever going to replace mammography? I think it's going to be a long time before that ever happens.